Medical records, documentation, tracking and order entry system

ABSTRACT

The new system provides: automatic incorporation of dictated text; medical records summary generation in medical English text; parsing dictation to data; prephrased text; automatic generation of medical record as consequence of data entry; automatic notation of allergies, significant medical conditions and pregnancy; pregnancy linking, automatically; security card--close on pull; multi-look grease board; outstanding orders listing for all patients in the department; department layout; room selection excludes occupied rooms; nurses notes to text; nurses notes from physician orders to nurses; lab request screen shows all previously ordered labs; therapeutics; ACLS recording; lacerations; doctor specific prescriptions and medication orders; review of systems; coding level alerts; differential diagnosis--filter to sex and age; diagnosis--fractures to text; doctor interval reexamination; patient instructions predicated on what was done; patient instruction video on demand; patient informed consent video on demand; video teleconferencing; electronic signatures; automatic backup and incremental backup with system on-line; critical management reports; and automatic research data extraction.

BACKGROUND OF THE INVENTION

Need exists for immediate triage, reports and medical records which maybe generated and supplied to physicians and nurses and which may betranslated into patient reports, instructions and prescriptions withoutdelaying or burdening hospital personnel.

SUMMARY OF THE INVENTION

The new system provides automatic incorporation of dictated text;medical records summary generation in medical English text; parsingdictation to data; prephrased text; automatic generation of medicalrecord as a consequence of data entry; automatic notation of allergies,significant medical conditions and pregnancy; pregnancy linking,automatically; security card close on pull; multi-look grease board;outstanding orders listing for all patients in the department;department layout; room selection excludes occupied rooms; nurses notesto text; nurses notes from physician orders to nurses; lab requestscreen shows all previously ordered labs; therapeutics; ACLS recording;lacerations; doctor specific prescriptions and medication orders; reviewof systems; coding level alerts; differential diagnosis, filter to sexand age; diagnosis, fractures to text; doctor interval reexamination;patient instructions predicated on what was done; patient instructionvideo on demand; patient informed consent video on demand; videoteleconferencing; electronic signatures; automatic backup andincremental backup with system on-line; critical management reports; andautomatic research data extraction.

The new computer system is accurate, comprehensive and fast. The presentinvention provides accuracy in documentation and speaks the language ofmedicine. It provides speed in documentation and captures time for everycare giver, not just physicians. The new system provides access to thedocumentation, eliminating constant hunting for the chart.

The invention generates a comprehensive document; a full and completemedical record. The new system provides triage, exit instructions,patient tracking and every phase of the encounter. Security, privacy andintegrity of data are maintained. The data is up to date and pertinent.Every facet of medical care is documented. Pharmaceutical, procedural,diagnostic and patient instruction data are current andstate-of-the-art. The system is built from the ground up to meet theunique needs of an acute care environment.

Pertinent and comprehensive patient care data are gathered. Thepatient's old records are organized for review on subsequent visits.Multiple visit patient data is instantly available. The new systemallows physicians to confirm that the right questions were asked, theappropriate exam elements were covered, the likely diagnoses wereconsidered, the appropriate treatment was rendered and consultation wasmade in a timely fashion. The invention reduces medicolegal liabilityand assures quality of care. Data is organized in a format that meetsHCFA criteria for proper billing for care rendered, meets E&M codingcriteria and facilitates CPT coding.

Data is accessible and maneuverable. Rapidly retrievable data generatesuseful management reports. Most information gathered is stored as data,not as text. The invention provides instant access to massive quantitiesof patient data. Storage techniques are innovative, allowingsimultaneous access and input to the same chart. Interface is providedwith outside data sources: registration, lab, X-ray, transcription,ancillary services, central supply, pharmacy and the clinical datadepository.

The invention enables research and remote analysis by real-time securedremote access to the database by primary and consulting physicians, aswell as other hospital facilities. The acquired clinical data isuploaded to central data warehouses for purposes of statistical analysisand research. With strict maintenance of patient-identifying data,privacy and confidentiality are assured.

The new computer system is extremely intuitive and easy to use. Itlimits disruption due to new personnel coming into the department.Clinical staff like to use it, which increases user satisfaction.Speeding of patient throughput increases patient satisfaction.Meaningful reports are provided to increase productivity in the acutecare setting. Individualized user preferences are accommodated withcustomized text entries. Doctors and nurses need not have world classtyping skills to use the system effectively.

Nursing and physician documentation are combined in the final medicalrecord. The system is transparent to the user, not distracting.

The importance of care giver decision making is emphasized, allowingpersonnel to use common sense on how and when to record information. Thenew system allows data entry in dependence. A user is not required tofill in every blank before proceeding to the next page. A consistentscreen "look and feel" reduces user fatigue, and facilitates speed andaccuracy.

T he overall cost of providing care is reduced to remain competitive inthe rapidly evolving world of managed care.

Automatic incorporation of dictated text into the computer generatedmedical record summary: the summary is formatted so as to make it easyfor the caregivers (doctors, nurses, clerks, ancillary servicespersonnel, orderlies, paramedical personnel, and other qualifiedpersonnel) to read and understand what is going on with the patient. Themedical record also has a Specific organization necessary for billingfor the care which is rendered. In order to produce a hybrid record inwhich much of the information is entered by clicking on buttons or checkboxes and combine this data with information which is dictated, it isimportant that the dictation go to the appropriate places in thesummary. For instance, a doctor may enter much of the information in theReview of Systems (ROS) by checking boxes. But he may wish to dictate asmall unique bit of information which is not present in the ROS screens.This dictated text is automatically inserted into the record at theappropriate location.

Medical records summary generation in medical English text in astandardized format from the data in the database: the nurses anddoctors put patient information into the chart using touch screen,mouse, keyboard, or by dictating to a transcriptionist. This is done onentry screens which have standardized look and feel so as to maintainfamiliarity with the layout and organization of a very large body ofinformation. This information load cannot be reduced if a comprehensiverecord is to be produced. When the summary is called up on screen or asa printout, all of the patient data is converted into medical Englishtext and reads as if it had been dictated by a nurse or doctor. Thisincludes the parts which were actually dictated. The summary isgenerated in under three seconds from thousands of clinical facts whichwere gathered during the process of patient care. The summary can becalled up at any time and will show everything that the medicalpersonnel have input about the patient up to that point.

Dictation: the portions of the medical record which are dictatedinitially are received by the communications server(s), analyzed forpatient and content, attached to the proper patient and visit and brokeninto its component medical parts. When a medical summary is produced,dictated text is attached to the proper part of the medical record. Thisallows summaries to include all data including information which wasinitially entered by dictation.

Prephrased text: these computer system data entry screens allow medicalpersonnel to select prestored personalized text phrases to be includedin specific medical record components. This makes including frequentlyused personalized text very fast. Once added to the record, the text isfully editable.

Automatic generation of the medical record as consequence of data entry:in every aspect of the computer system, information that is input in oneplace is included in all places that are relevant. Many caregiversprovide input of information into a patient's medical record. The inputis added at different times from different locations. Some of the datacomes from other departments. All of the acquired data is collated intoa properly formatted medical record automatically. This may be output toa screen as a summary or printed. If the patient dictation returns afterthe patient is released from the department, the printed record isgenerated automatically.

Automatic notation of allergies, significant medical conditions andpregnancy: on all medication entry screens and on screens where a nurseexecutes an order for medication, pertinent medical conditions are notedto prevent medical complications.

Security card close on pull: the computer system has security measureswhich limits access to the system. Patients, family members, or othersare prevented from looking into medical records or entering information.The caregiver approaches a station terminal and inserts a security card.The local station terminal becomes active. The user is automaticallyidentified and areas in which the user has "rights" are made available.All entries are attributed to the correct user. When entries arecomplete, the card is pulled from the reader. The computer system storesall entered data and the terminal is returned to a protected state.

Patient tracking: Various displays provide the state of the hospitaldepartment indicating patient location, doctor assignment, patientstatus, and order status.

Nurses notes to text: 95% of all the nurses notes are generated bysimple selections on screens in the nurses notes section. Little typingis necessary for producing comprehensive nursing notes. Physician ordersare automatically queued for nurses, and can be "picked off" to recordthe activity in the medical record and indicate completion.

Labs, radiology, and tests can be ordered and results automaticallyreturned to the system.

Therapeutics: a comprehensive selection of therapeutics can be enteredas performed or generate orders for others to complete.

ACLS recording: ACLS procedures and observations can be quickly enteredas they are performed. At any time, a quick summary of proceduresperformed with elapsed times can be displayed.

Lacerations: documentation of laceration repair allows for proceduresperformed on each tissue layers on multiple lacerations.

Doctor specific prescriptions and medication orders in the department:each doctor can have a physician-specific list of medications which arefrequently prescribed. Both in-department drug orders and prescriptionscan be generated using a physician-specific drug list, alphabeticalmaster list, or category-based list. Generated prescriptions includedrug-specific patient instructions in English or Spanish.

Review of systems: the system easily tracks review of system responses,automatically grouping answers into appropriate body system andseparating pertinent negatives from positive responses. Body systemheadlines aid in proper coding for care rendered.

Coding level alerts: when patient complaints are entered, the systemindicates to users medical information that should be collected toreceive proper coding for billing. As the appropriate information iscollected, other indicators so indicate. This assures that all pertinentinformation is entered into the medical record. It aids in increasingthe quality of care rendered and in the coding level which can beattained for the care rendered.

Differential diagnosis: the system automatically generates acomprehensive sex and age specific differential diagnosis based on thepatient's complaint(s). A preselected multi-level sublist of the mostlikely diagnoses is included.

Diagnosis: a diagnosis can be selected from the differential diagnosis,or created using body part graphics to indicate injuries.

Doctor Interval Reexamination: each time a physician visits a patient,the system can document the date/time of the visit.

Patient instructions predicated on what was done: the computer systemproduces discharge instructions to the patients telling them about theirillness or injury, about what was done for them, as well as what theyshould do to care for themselves at home. Warnings are given to patientsto return to the medical facility or seek further care when necessary.The instructions also list referrals. In most circumstances theseinstructions are entered automatically based on the patient'scomplaints, diagnoses, and treatment rendered.

These and further and other objects and features of the invention areapparent in the disclosure, which includes the above and ongoing writtenspecification, with the claims and the drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 schematically shows the system network FIGS. 2-7 schematicallyshow functional linking.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

A medical records, documentation, tracking and order entry system 1 isshown in FIG. 1. Fault tolerant file servers 2 and support and backupservers 3 use standard disk drives or fully redundant arrays of driveson each server. A communications server(s) 4, linked to each of the fileservers, receives incoming transcription 5. A network has a hub 7connected to the file servers 2 and 3 by data lines 8. Peripheralterminals 9 are connected to the network in a star configuration withthe hub. The peripheral terminals 9 have individual central processingunits 10 with hard disks. Touch screen 11, monitors 12, keyboards 13 andmouses 14 are connected to the CPU'S. Software resides in thecommunication server(s) 4, in the dual file servers 2 and 3 and in theperipheral CPU's 10. Patient data is received in the peripheral CPU'svia the touch screens, mouses, and keyboards and for storing the patientdata in the peripheral CPU's and file servers. A distributed dictationsystem has inputs adjacent to the CPU'S. A transcription system 5 isconnected to the multiple inputs and is connected to the communicationserver(s) 4. Transcribed dictation is received in the communicationsserver(s) 4. The transcribed dictations are placed in an electronicstorage bin in the communications server(s) for transferring thedictation transcriptions to the file servers, and storing the dictationtranscriptions in the file servers 2 and 3 as text associated withpatient data for particular patients. A printer 15, connected to thenetwork, generates reports on individual patients and management reportsof system operations of statistical information, doctor relatedactivities, nursing related activities and patient statistics.

A triage printer 16 in the department prints information about patients'complaints, locations and physician and nurse assignments, and printslists of patients in the order of immediacy. Other printers 17 may belocated in other locations within the department or in otherdepartments. A fax 19 is connected to the network 6 to send printeddocuments over telephone lines to remote locations.

Uninterruptable power supplies 20 supply power to all the local systems.Other departments 21 are connected to the master server 2 to receivedata from other departments and to send data to the other departments.

A telephone system 22 provides communications with remote offices suchas doctor's offices 23, and a transcription service which servestranscribers 5. Modems 24 are connected to the communications server(s)4 for communicating with doctors' offices, transcribers and support fromthe system suppliers. An ISDN data network 25 is connected in parallelwith the modems 24 to connect with the supplier's support 26, thedoctor's offices 23 and transcribers 5.

The patient record documentation method provides tracking and orderentry. File servers provide data and software from the file serversthrough a network hub and network to multiple CPU'S. The patient data istransferred from the CPU's to the file servers. Portions of the recordthat are unique to particular patients are dictated. The dictation istransmitted over voice lines to a transcription center where thedictation is transcribed. The transcribed dictation is transmitted tothe communication server(s), which feeds the dictation transcription tothe file servers as text components. The text on particular patients isstored in the file server with the tabled data. Word and sentencegeneration and coordination software is stored in the peripheral CPU'S.Monitors display text sentences generated by the generation software assummaries, together with the text from the dictation transcriptions. Thetext summaries are sent from the peripheral CPU's to a printer via thelocal network for generation of printed patient textual reports withsentences generated in medical English text.

Nurses' notes are entered as data on touch screens, mouses andkeyboards. The data of nurse's notes is transferred from the peripheralCPU's to the file servers, which stores the nurse's notes information asdata. The nurse's notes data is transmitted to the peripheral CPU's,which recompile the data into nurse's notes text, display the nurse'snotes as text on the peripheral CPU monitor screens and print thenurse's notes text on the printer.

Prephrased text examples are stored in the file servers. Individualphysicians and nurses preliminarily select prephrased text examples aspersonalized text for compiling with data to produce medical Englishtextual summaries and reports.

Nurse's orders are generated by entering physician orders to nurses atperipheral CPU'S. The physician orders are transmitted as physicianorders data to the file servers. Physician orders data are stored withthe patient tabled data in the file servers. Physician orders data areprovided from the file servers to the peripheral CPU's, which displaythe physician orders data as textual nurse's orders on the CPU's, printnurse's orders, display all outstanding nurse's orders on the CPU's onrequest and display all nurse's orders specific to the patient. Enteringexecutions of the nurse's orders on the patient display automaticallychanges the executed nurse's textual notes for display in summaries.

Patient record documentation tracking and order entry starts withlogging on to a peripheral CPU, displaying the user's name and theactive patient list "grease board," and showing room location, patient'sname and physician, nursing orders, priority and elapsed time of stay,and status of assignment of nurse and physician, ordering of X-rays,labs and tests, nurse's orders, records, dictation and vital signs.

Status is shown in small letters for ordering of X-rays, labs, tests,nurses' orders and dictation, and large letters to indicate completionof X-rays, labs, tests, nurse's orders and dictation transcripts.

Active patient list information is displayed in a department layout.

A screen shows a list of patients waiting to be seen by a physician, inthe order of priority. Another display shows patient lists by patientcomplaints. A further display lists patient lists by those whose chartshave not been dictated by the physician.

In FIGS. 2-7 of the drawings, showing the functional linking of theprogram, the double-line boxes with italic text show actions by users.The heavy line boxes with bold text show program modules. The singleline boxes with Roman text show results or output.

Arrows show direct routing.

Moving from left to right across the page, the functions are subfunctions or accessed functions from those toward the left. In otherwords, moving from left to right drills down into deeper functions ofthe program.

The reference numbers are used to provide additional text detail aboutthe box being referenced. TeleMed denotes the invention.

Broken lines allow the break-up of sections and movement to the left soas not to run out of room moving across the page.

All modules, where appropriate, record data to the medical record withtime/date stamps and who performed the function.

101. Security Validation Module--Personnel using the system must clearlydemonstrate their identity using a variety of methods depending on thesystem configuration. Single and multiple passwords, smart cardtechnology, magnetic card or other personal ID technologies. The user'sidentity establishes the individual "rights" to use various functions.For example, physicians may be the only users given rights to generateprescriptions, nurses could have rights to implement various medicalprocedures, ward clerks might need rights to order labs, but recordsclerks may be limited to changing demographic information. When smartcards are used, the system is available only while a proper, authorizedcard is inserted. Upon withdrawal, the system completes any processesand reverts to a non responding mode.

102. Tracking Module--Medical personnel can quickly see the status ofboth individual patients and the entire department. TeleMed initiallydisplays an active patient list showing all patients within thedepartment. This display also provides a variety of additional pertinentinformation such as location, priority, elapsed time since entering thedepartment, order status, vitals status and assigned physician.

This information can be presented in a variety of formats, sometimeswith additional information, to help the department personnel quicklyobtain the patient tracking information they need. Department layoutdisplays a map of the department showing occupancy (and availability)and physician assignments. Waiting patients shows patients in the orderthey should be taken. Patient complaints presents patients with theirassociated complaints. A patient can be selected from any of thesedisplays to enter his/her individual medical record.

Other displays show outstanding orders and the latest vitals on eachpatient.

This module also controls creation of new visits and, if the patient hasnever previously visited the hospital, creation of new patient records.New visits can be created without knowing the patient identification.Identification can later be changed here when such information isavailable.

Historical medical records can be located using a variety of patientinformation such as name, social security number or previous hospitalnumbers. Using a name will display all patients with similar names withadditional identifying characteristics such as birth date. The specificpatient can be selected and previous visits will be displayed withcomplaints. Selection of a visit provides access to a medical recordsummary for that visit.

103. Directory Module--Provides a directory of physicians and otherservices. Can be filtered to physicians with specific specialties and/ormanaged care affiliations. Physician preferences to be notified if apatient enters the hospital and referral preferences are included.

104. Utilities Module--This sections handles reports, system management,and data maintenance. Management includes editing users, doctor drugprescription preferences, doctor drug order preferences, prephrasedtext, and other system functions. Reports can be created for any timeperiod. They include department status, department statistics,transcript status, length of stays, repeat visit statistics, mortality,outcomes analysis, etc.

An extensive selection of physician and management reports areavailable. Since TeleMed stores medical facts as discrete facts ratherthan text, extensive analysis of an extremely wide variety of medicalrelationships can easily be accomplished.

A variety of maintenance utility functions are included.

105. Language Generation Module--A key function within the TeleMedprogram is the language generator. TeleMed stores most medicalinformation as individual specific medical facts rather than as text.When displaying these facts in an on-screen medical summary or onprinted medical records, these facts are quickly converted to complexsentence structure similar to physician's dictated medical text.

The language generator builds sentence structure, often containingmultiple related facts taken from widely separated points within theprogram. The program uses a pronoun sequencing technique which producesmedical language more like the way medical personnel actually recordmedical records.

Medical facts are analyzed for responses and type in relation to thepatient's sex and age, then converted to initial sentence structure.Where appropriate, the language generator intelligently rearranges theorder in which facts were entered to provide the information in a moreusable and medically appropriate format. The structure is analyzed andmodified if compound sentences can linguistically improve structure.Text such as dictation is analyzed for type and integrated into theprevious structure. All text is then analyzed as to the need forheadlines and subheads. Needed heads are inserted. The use of boldincreased-size headings for major sections and bold or italic subheadsallow for quick viewing and easy location of specific facts.

106. To Screen or Printer Module--This module formats text toappropriate output. Manages screen display and movement or managesprinter page output.

Output from the language generator module is analyzed and reformattedfor the requested output mode (screen or print).

Medical records are printed in a typeset format whereby all medicalfacts are grouped under the proper medical headings.

The module can automatically fax a copy of the patient's record to thepatient's private physician or generate an extra copy of medical recordsfor patients with specific diagnosis or other characteristics for audit.

107. Master Patient Module--Controls routing to all patient-specificscreens. Controls specific patient location and priority (passed toPatient Tracking Module). Movement of a patient is noted by a simpleselection of available locations (occupied beds are excluded from theselection). Manages billing coding level alerts used to warn medicalpersonnel that the medical record is incomplete to support the level ofbilling possible based on accumulated facts about the visit. Indicatorsshow what additional information should be collected. Manages masteralerting system to warn medical personnel of significant medicalconditions.

This module also performs ongoing statistical trend analysis of patientdata to alert medical personnel of dangerous long-term trends in thepatient's medical condition.

Input and output of liquids and solids by the patient, bed generatedpatient weight and direct incorporation of monitoring device output areautomatically tracked.

Physician electronic signatures can be added to the medical record.

108. Triage Module--This section collects specifics about the medicalencounter that pertain to fulfilling legal hospital requirements fortriage. Many responses are later intelligently used by the system. Factssuch as pregnancy status later cause the system to automatically alertmedical personnel as procedures are about to be performed, and warnpersonnel when orders are given (such as specifying abdominal protectionwhen x-rays are ordered). Upon completion of triage, a triage summaryproduced by the language generator can be printed.

109. Complaints Module--TeleMed is a complaint driven system. Thismodule manages complaints, differential diagnosis and diagnosis. Ascomplaints are entered, the system begins to automatically modify laterfunctions so department personnel deal with a dramatically reduced arrayof selections. For example, a comprehensive differential diagnosis isfiltered to only those appropriate to the complaint, sex and age, and arecommended multilevel subset (none, light, medium or heavy variationsare set by physician preferences) is used as a starting point forphysicians to place in the medical record. They can then easily add toor delete from this starting point. Patient instructions relating to acomplaint/diagnosis are automatically queued.

When a complaint is selected, an extensive knowledgebase is used by theprogram to establish parameters the program will follow throughout therest of the visit. These parameters guide the program in selection ofscreens (such as to address the appropriate sex), generation of text,billing code levels, order restrictions or enhancements, etc. As theencounter progresses, the parameters are modified by the program to fitnew facts collected.

The system can store photos of injuries or conditions taken with adigital camera directly into the patient's medical record.

The final diagnosis(es) can be easily selected from (but is not limitedto) the differential diagnosis. Trauma diagnosis(es) can be selectedfrom graphic presentations of the appropriate body parts. For example, aparticular fractured bone and the fracture location, characteristics,and type can be indicated on a graphical display of the body part.TeleMed converts the fracture facts into proper medical languagedescribing the injury.

110. Patient History Module--Patient histories and current conditionsare collected using a series of screens providing a comprehensiveselection of medical facts on allergies, past medical history, familyhistory, social history and a comprehensive review of systems which canbe easily selected to indicate positive responses and, whereappropriate, pertinent negative responses.

111. Nurse Notes Module--This series of screens allows nurses to easilyselect ordered procedures which have been performed, indicate otheractivities they have performed, record vitals, note observations orpatient responses. Nurses can also pre-queue patient instructionsassociated with their activities. Orders made by physicians are queuedso nurses can "pick off" an order to fully document the completion ofthe order. Electronic signatures can be added to a nurse's portion ofthe medical record.

112. Prephrased Text Module--Medical person specific or system wideblocks of text can be personalized. When selected, text blocks areautomatically copied to the appropriate medical component of the medicalrecord. They can then be easily modified in the transcript module, ifnecessary.

113. Transcript Module--Dictated text can be automatically integratedinto the appropriate medical component of the record. Physicians candictate parts of the medical record to a dictation company or in-housedictation department. The department can send the dictation back toTeleMed by modem or other link and TeleMed will automatically connectthe dictation to the proper patient, separate the paragraphs and linkthem to the appropriate part of the patient's medical record. Oncereceived, appropriate medical personnel can fully edit dictation text tofix errors or enhance the text with additional information.

Medical personnel can type text into the record if they choose, or usepersonalized prephrased text (text blocks previously entered by thephysician) to enter preferred phraseology into the medical record.

114. Review of Systems Module--Review of systems is collected using aseries of screens providing a comprehensive selection of medical factson body systems. Extensive body subsystems are included. Responses canbe easily selected to indicate positive responses, and where appropriatepertinent negative responses.

The module manages billing coding level alerts for review of system bodysystems used to warn medical personnel that this portion of the medicalrecord is incomplete to support the level of billing possible based onaccumulated facts about the visit. Indicators show what additionalinformation should be collected. Coding alerts passed to master patientmodule for overall management.

The module also notifies the alerting system to warn medical personnelof significant medical conditions.

115. Drug Allergies Module--Drug allergies are tracked. The modulenotifies the alerting system to warn medical personnel of such allergiesand where appropriate, drug interactions.

116. Lab Module--This section contains a comprehensive selection of labtests and procedures to be ordered and tracked. A user can automaticallygenerate orders within the appropriate hospital department and providethe ward clerk with a record of the order. Labels for laboratory testsource materials are automatically printed. Lab results can beautomatically deposited back into the TeleMed system. The return ofresults are automatically flagged on the active patient list screen toalert medical personnel.

Lab results which impact medical personnel actions, such as a result ofpregnant, cause TeleMed to automatically begin alerting personnel tosuch conditions and future orders intelligently react to the condition.For example, an X-ray order would automatically indicate that theabdomen should be protected.

Results not received in a department specified time generate an alert.

All previous lab orders for a specific visit can be displayed to helpprevent unnecessary duplication.

117. Radiology and Test Module--These section contains a comprehensiveselection of radiology and test procedures to be ordered and tracked. Auser can automatically generate orders within the appropriate hospitaldepartment and provide the ward clerk with a record of the order.Results can be automatically deposited back into the TeleMed system. Thereturn of results is automatically flagged on the active patient listscreen to alert medical personnel.

Results which impact medical personnel actions cause TeleMed toautomatically begin alerting personnel to such conditions and futureorders intelligently react to the condition.

Results not received in a department specified time generate an alert.

All previous radiology and test orders for a specific visit can bedisplayed to help prevent unnecessary duplication.

118. Diagnostics and Therapeutics Module--A comprehensive entry systemfor ordering or performing medical procedures. Procedures can berecorded upon completion or orders can be generated. If orders are made,a paper record of the order is created and the order is placed in queuefor medical personnel to complete. The queuing system automatesrecording the completion of the order by personnel performing the task.

When procedures are performed, where appropriate, patient instructionsare automatically queued.

119. ACLS Module--ACLS actions are recorded by selecting the procedureor observation and clicking record. Accumulated ACLS actions can beimmediately displayed at any time with elapsed times since each action.

120. Laceration Module--TeleMed handles any number of lacerations perencounter and tracks activity performed overall, on each tissue layer,and on each laceration while pre-queuing appropriate patientinstructions.

121. Inventory Control Module--This module controls the inventory andaccess for pharmaceutical and other materials used in the department. Anautomatic reordering system linked to other hospital systems isincluded.

122. Video System Module--The video instruction system is managed bythis module. On demand, digital video instructions and educationprograms can be played for the patient through the terminal or anoptional alternate screen. Video programming is also included to assistin obtaining informed consent for performing medical procedures.

123. Drug Module--Both a customizable physician-specific drug list and acomprehensive master drug list are available. The physician-specificlist allows physicians to prescribe or order medications in theirpreferred manner, even allowing for the multiple entry of the same drugwith different dosing. The master list can be accessed by entering thefirst few letters of the drug name or selection can be made by drugclassification. Medications from the master list provide a defaultnormal SIG for the drug, which can easily be modified. Drug interactionalerts are included.

Prescriptions include complete printed instructions in English orSpanish on use of the drug.

124. Consultation Module--Consultants can be selected from a directory.The directory displays all consultants or consultants filtered formedical specialty and/or managed care affiliations. A record of theconsultation, along with timing and documentation of the discussion arerecorded. If the consultant does not return a call within a departmentspecified time period, an alert is generated.

125. Referrals Module--Referrals can be selected from the directory. Thedirectory displays all consultants or consultants filtered for medicalspecialty and/or managed care affiliations. Referrals will print on thepatient instructions along with specialty, phone numbers, addresses, andappointment times (if any).

126. Dr. Interval Module--The physician can record each time he/shechecks the patient.

127. Medical Summary Module--This module specifies the range of facts,method of display, routing of output and other factors needed by thelanguage generator.

128. Nurse Notes Summary Module--This module specifies the range offacts associated with nurse activity, method of display, routing ofoutput and other factors needed by the language generator.

129. EKG Results Module--This module specifies the range of factsassociated with EKG results, sets display to the screen, and establishesother factors needed by the language generator.

130. Patient Instructions Module--Integrated patient instructions areautomatically queued based on the patient's condition and what was done.Instructions can be added or deleted from the queue before printing.

Printed instructions include a list of prescriptions, referrals andother significant information about the visit.

131. Work/School Excuse Module--Outputs patient work or school excusenoting services performed, when to return, limitations on activity, andreferrals.

132. Demographics Module--This module tracks a comprehensive array ofpatient demographics including contact information, religion, insurance,employer, guarantor, etc. With insurance companies and governmentagencies that are equipped, automatic electronic insurance verificationis made.

133. Department Clerk Module--Manages status of orders to otherdepartments, and time delay alerts for non completion of orders.

134. Teleconferencing Module--From any point within the system (or fromproperly authorized remote locations) to any other point in the system,medical personnel can link terminals and have visual conferences.Medical personnel can link directly to a patient's room terminal andanswer queries. Physicians can link from their office and have aconference with department personnel or the patient. Physicians in theiroffice can remotely examine the electronic medical record and placeorders or enter information into the medical record.

135. Research Module--This module can automatically strip identifyingdemographics from medical records and produce various analysis forgeneration of research data. Research protocols and outcome analysis canalso be managed.

136. Transcript Text Analysis Module--TeleMed's communications serverreceives the text from the dictation source. This module analyzes thetext for tags which identify the patient, dictating physician, time anddate dictated and other data. Paragraphs are analyzed for tagsindicating the medical record component associated with each paragraph.The dictation is then broken into paragraph based components, linked tothe proper patient, date and timed stamped, and stored.

The module specifies the range of facts, method of display, routing ofoutput and other factors needed by the language generator. The languagegenerator is queued to automatically print medical records upon receiptof a transcript for any outstanding dictation if the patient is nolonger in the department.

137. Automatic Backup Module--Provides automatic on-line back-up data.At department specified frequency, the module also backs-up all datachanged since the last full back-up (interim backups).

138. Scheduling Module--This module manages scheduling of personnel fordepartment coverages.

139. Interface Module--Interface, and data mapping to exchange data withother systems is managed by this module.

TeleMed is a comprehensive system for the automatic generation of amedical English sentence structured medical record as a consequence ofindividual factual data entry. The look and feel of the program isdesigned to make the program easy to use by medical personnel havinglittle or no computer experience and to dramatically shorten thelearning curve to become competent in using the system.

TeleMed stations with touch screens are placed at each bedside, nurseand physician stations, triage, clerk desks and other appropriatelocations.

Use of the system is accomplished by using either the touch screen,keyboard or mouse and selecting a screen button or box to move throughthe program or enter medical facts. Values can be entered by keyboard.The system intelligently selects appropriate variations of screens tofit the patient (such as appropriate sex).

Personnel using the system must clearly demonstrate their identity usinga variety of methods depending on the system configuration. Single andmultiple passwords, smart card, magnetic card or other personal IDtechnologies. The user's identity establishes the individual "rights" touse various functions. For example, physicians may be the only usersgiven rights to generate prescriptions, nurses could have rights toimplement various medical procedures, ward clerks might need rights toorder labs, but records clerks may be limited to changing demographicinformation. If smart cards are used, the system is available only whilea proper, authorized card is inserted. Upon withdrawal, the systemcompletes any processes and reverts to a non responding mode

Remote access to the system is controlled by "firewall" softwareroutines which require varying security levels up to a forced returnlink initiated by the system to authorized remote computers or systems.

Medical personnel need to quickly see the status of both individualpatients and the entire department. TeleMed initially displays an activepatient list showing all patients within the department. This displayalso provides a variety of additional pertinent information such aslocation, priority, elapsed time since entering the department, orderstatus, vitals status and assigned physician.

This information can be presented in a variety of formats, sometimeswith additional information, to help the medical personnel quicklyobtain the patient tracking information they need. Department layoutdisplays a map of the department showing occupancy (and availability)and physician assignments. Waiting patients shows patients in the orderthey should be taken. Patient complaints presents patients with theirassociated complaints. A patient can be selected from any of thesedisplays to enter his/her individual medical record.

Other displays show outstanding orders and the latest vitals on eachpatient.

Historical medical records can be located using a variety of patientinformation such as name, social security number or previous hospitalnumbers. Using a name will display all patients with similar names withadditional identifying characteristics such as birth date. The specificpatient can be selected and previous visits will be displayed withcomplaints. Selection of a visit provides access to a medical recordsummary for that visit.

Movement of a patient is noted by a simple selection of availablelocations (occupied beds are excluded from the selection).

TeleMed tracks a comprehensive array of patient demographics includingcontact information, religion, insurance, employer, guarantor, etc.

The triage portion of the program allows personnel to begin enteringpatient facts before knowing the patient identification. This sectioncollects specifics about the medical encounter that are laterintelligently used by the system. Facts such as pregnancy status latercause the system to automatically alert medical personnel as proceduresare about to be performed, and warn personnel when orders are given(such as specifying abdominal protection when x-rays are ordered). Uponcompletion of triage, a triage summary produced by the languagegenerator can be printed.

TeleMed is a complaint driven system. As complaints are entered, thesystem begins to automatically modify later functions so personnel dealwith a dramatically reduced array of selections. For example, acomprehensive differential diagnosis is filtered to only thoseappropriate to the patient's complaint, sex and age, and a recommendedmultilevel subset (none, light, medium or heavy) is used as a startingpoint for physicians to place in the medical record. They can theneasily add to or delete from this starting point. Patient instructionsrelating to a complaint/diagnosis are automatically queued.

When a complaint is selected, an extensive knowledgebase is used by theprogram to establish parameters the program will follow throughout therest of the visit. These parameters guide the program in selection ofscreens (such as to address the appropriate sex), generation of text,billing code levels, order restrictions or enhancements, etc. As theencounter progresses, the parameters are modified by the program to fitnew facts collected.

The final diagnosis(es) can be easily selected from (but is not limitedto) the differential diagnosis. Trauma diagnosis(es) can be selectedfrom graphic presentations of the appropriate body parts. For example, aparticular fractured bone and the fracture location, characteristics,and type can be indicated on a graphical display of the body part.TeleMed converts the fracture facts into proper medical Englishdescribing the injury.

A series of screens provides a comprehensive selection of medical factson allergies, past medical history, family history, social history and acomprehensive review of systems which can be easily selected to indicatepositive responses, and where appropriate pertinent negative responses.

The nurse notes series of screens allows nurses to easily select orderedprocedures which have been performed, indicate other activities theyhave performed, record vitals, note observations or patient responses.Nurses can also pre-queue patient instructions associated with theiractivities. Orders made by physicians are queued so nurses can "pickoff" the order to fully document the completion of the order.

The ordering section contains a comprehensive selection of labs,radiology procedures and other tests to be ordered and tracked. A usercan automatically generate orders within the appropriate hospitaldepartment and provide the ward clerk with a record of the order.Results from these departments can be automatically deposited back intothe TeleMed system. The return of results is automatically flagged onthe active patient list screen to alert medical personnel.

Lab results which impact medical personnel actions, such as a result ofpregnant, cause TeleMed to automatically begin alerting personnel tosuch conditions and future orders intelligently react to the condition.For example, an X-ray order would automatically indicate that theabdomen should be protected.

All previous lab, radiology or test orders for a specific visit aredisplayed to help prevent unnecessary duplication.

The procedures section is a comprehensive entry system for ordering orperforming medical procedures. Procedures can be recorded uponcompletion or orders can be generated. If orders are made, a paperrecord of the order is created and the order is placed in queue formedical personnel to complete. The queuing system automates recordingthe completion of the order by personnel performing the task.

When procedures are performed, where appropriate, patient instructionsare automatically queued.

Advanced cardiac life support (ACLS) actions are recorded by selectingthe procedure and clicking on record. Accumulated ACLS actions can beimmediately displayed at any time with elapsed times since each action.

TeleMed handles any number of lacerations per encounter and tracksactivity performed overall, on each tissue layer, and on each lacerationwhile pre-queuing appropriate patient instructions.

Both a customizable physician-specific drug list and comprehensivemaster drug list are available. The physician-specific list allowsphysicians to prescribe or order medications in their preferred manner,even allowing for the multiple entry of the same drug with differentdosing. The master list can be accessed by entering the first fewletters of the drug name or by drug classification. Medications from themaster list provide a default normal SIG for the drug, which can easilybe modified.

Generated prescriptions include complete printed instructions in Englishor Spanish on use of the drug.

Consultants can be selected from a directory. The directory displays allconsultants or consultants filtered for medical specialty and/or managedcare affiliations. A record of the consultation, along with timing anddocumentation of the discussion are recorded.

Referrals can be selected from the same directory. Referrals will printon the patient instructions along with specialty, phone numbers,addresses, and appointment times (if any).

TeleMed automatically integrates dictated text into the appropriate partof the medical record. Physicians can dictate parts of the medicalrecord to a dictation company or in-house dictation department. Thedepartment can send the dictation back to TeleMed by modem or other linkand TeleMed will automatically connect the dictation to the properpatient, separate the paragraphs and link them to the appropriatecomponent of the patient's medical record.

TeleMed's communications server(s) receives the text from the dictationsource. The text is analyzed to identify the patient, dictatingphysician, time and date dictated and other data. Paragraphs areanalyzed for tags indicating the medical record component associatedwith each paragraph. The dictation is then broken into paragraph basedcomponents, linked to the proper patient, date and timed stamped, andstored.

Once received, appropriate medical personnel can fully edit dictationtext to fix errors or enhance the text with additional information.

Physicians can type text into the record if they choose, or usepersonalized prephrased text (text blocks previously entered by thephysician) to enter preferred phraseology into the medical record.

The physician can record each time he/she checks on the patient.

Integrated patient instructions are automatically queued based on thepatient's condition and what was done. Instructions can be added ordeleted from the queue before printing.

Printed instructions included a list of prescriptions, referrals andother significant information about the visit.

A key function within the TeleMed program is the language generator.TeleMed stores most medical information as individual specific medicalfacts rather than as text. When displaying these facts in an on-screenmedical summary or printed medical record, these facts are quicklyconverted to complex sentence structure similar to a physician'sdictated text.

The TeleMed language generator builds sentence structure, oftencontaining multiple related facts taken from widely separated pointswithin the program. The program uses a pronoun sequencing techniquewhich produces medical sentences sounding more like the way medicalpeople actually record medical records.

Medical facts are analyzed for responses and type, reordered andconverted to initial sentence structure. Text such as dictation isanalyzed for type and integrated into the previous structure. The textis then analyzed for the need for headlines and subheads. Needed headsare inserted. The entire block is analyzed and reformatted to combineand rebreak text lines at appropriate points. The block is reanalyzedand reformatted for positioning on the appropriate output (screen orprint).

Medical records are printed in a typeset format whereby all medicalfacts are grouped under the proper medical headings. Where appropriate,TeleMed intelligently rearranges the order in which facts are entered toprovide the information in an extremely usable format. The use of boldincreased-size headings for major sections and bold or italic subheadsallow for quick viewing and easy location of specific facts.

The medical record is automatically printed upon receipt of anyoutstanding dictation if the patient is no longer in the department.

TeleMed can automatically fax a copy of the patient's record to thepatient's private physician.

The program can also automatically generate an extra copy of medicalrecords for patients with specific diagnosis or other characteristicsfor audit.

Coding level alerts are used to warn medical personnel that the medicalrecord in incomplete to support the level of billing possible based onaccumulated facts about the visit. Indicators show what additionalinformation should be collected.

An extensive selection of physician and management reports areavailable. Since TeleMed stores medical facts as discrete facts ratherthan text, extensive analysis of an extremely wide variety of medicalrelationships can easily be accomplished.

A variety of maintenance utility functions are included.

A set of wound treatment screens provides a method for documentingmultiple layers of repair using different suture techniques on differenttissue layers with different suture material.

Each time a doctor visits a patient can be recorded, along withdate/time data, by TeleMed.

A graphical representation of all bones in the body can be displayed sospecific bones, location on the bone, type of fracture, and otherfracture related facts can be indicated. The peripheral CPU stores thefact data and also generates a medical English description of thefracture for review. The CPU sends the data and text to the file serversfor storage as diagnoses. Patient instructions associated with fracturerepair procedures are automatically queued by TeleMed.

The review of systems uses a series of screens on the peripheral CPU'swhereby entries are made by touching or clicking a mouse on the checkboxes, thereby recording data about certain specific organ systems inquestion. That data is then transferred as data to the file servers andis stored as data.

The coding level alerts are a method by which the software on theperipheral CPU generates check marks next to the screen data entrybuttons, which notify the treating nurse to go into those screens andenter that specific data. The check marks are generated by the entry ofspecific complaints made by a patient. Specific check marks areconverted into diamonds when sufficient medical data has been collectedto meet coding level requirements for that medical component or functionin association with accumulated single or multiple complaintrequirements.

Pregnancy linking is a methodology by which, if the patient is stated tobe or determined to be pregnant, or possibly pregnant, TeleMedautomatically alerts medical personnel to take precautions whenprocedures, such as X-rays are to be performed. TeleMed alsoautomatically calculates the estimated date of completion andgestational age.

Upon completion of the medical encounter, or at any time during theencounter, TeleMed can generate a complete medical English summary ofall accumulated information about the encounter. If dictation has beenmade, TeleMed will automatically process the transcription text into thepatients medical record for that specific visit and generate a printedsummary.

An example of a complete generated patient report, lab and radiologyrequests, patient instructions and prescription follows.

EXAMPLE ##SPC1##

While the invention has been described with reference to specificembodiments, modifications and variations of the invention may beconstructed without departing from the scope of the invention, which isdefined in the following claims.

We claim:
 1. A medical records, documentation, tracking and order entrysystem, comprising at least one fault tolerant file server having atleast one fault tolerant backup server, wherein the at least one fileserver has either standard hard drives or redundant array of independentdrives, a software vendor, at least one communications server linked tothe at least one file server for receiving incoming transcription andfor remote reception of software, maintenance and system updates fromthe software vendor, a network having a hub and being connected to thefile server, peripheral terminals connected to the network in a starconfiguration with the hub, the peripheral terminals having individualcentral processing units (CPUs), the CPUs having hard disks, touchscreens, monitor, keyboards and mouses connected to the CPUs; softwareprovided in the at least one communication server, in the at least onefile server, and in the peripheral CPUs for receiving patient data inthe peripheral CPUs via the touch screens, mouses, and keyboards and forstoring the patient data in the peripheral CPUs and the at least onefile server; and a distributed dictation system having inputs adjacentthe CPUs, a transcription system for receiving and converting dictationfrom the inputs into transcribed dictations and the transcription systembeing connected to the at least one communication server fortransmitting the transcribed dictations to the at least onecommunications server and an electronic storage bin connected to the atleast one communication server for placing the transcribed dictations inthe electronic storage bin and for transferring the transcribeddictations to the at least one file server, the electronic storage binstoring the transcribed dictations as text associated with the patientdata for particular patients, printers connected to the network forprinting reports on individual patients and system management reports ofsystem operations, doctor related activities, nursing related activitiesand patient statistics.
 2. A method of patient record documentation,tracking and order entry, comprising providing software in file servers,providing software from the file servers through a network hub andnetwork to multiple peripheral CPUs, inputting data on data entryscreens on monitors connected to the CPUs, the inputting comprisingentering patient data in the multiple CPUs by touch screens, mouses andkeyboards in response to the data entry screens on monitors connected tothe CPUs, transferring the patient data from the CPUs to the fileservers, making a record for individual patients, dictating portions ofthe record that are unique to particular patients, transmitting thedictation over lines to a transcription center, transcribing thedictation and transmitting the dictation transcriptions to at least onecommunication server, feeding the dictation transcriptions to the fileservers as text, storing the text with the patient data on particularpatients in the file servers, storing word and sentence generation andcoordination software in the peripheral CPUs, generating text sentencesin medical English text from patient data, displaying on the monitorsconnected to the peripheral CPUs the text sentences in medical Englishtext combined with the text from the dictation transcriptions assembledas text summaries, and providing the text summaries from the peripheralCPUs to printers via the network for generation of printed patienttextual reports.
 3. The method of claim 2, further comprising installingutility software in the peripheral CPUs and generating managementreports in the peripheral CPUs by calling the patient data over thenetwork from the file servers and compiling the patient data as text anddirecting the compiled data to the printer.
 4. The method of claim 2,further comprising producing nurses' notes data by entering the patientdata with touch screens, mouses and keyboards, transferring the nurses'notes data from the peripheral CPUs to the file servers, storing thenurses' notes data in the file servers, transmitting the nurses' notesdata to the peripheral CPUs, recompiling the nurses' notes data intonurses' notes text in the CPUs, displaying the nurses' notes text onperipheral CPU monitor screens, and printing the nurses' notes text onthe printer.
 5. The method of claim 2, further comprising storingprephrased text examples in the peripheral CPUs, and preliminarilyinputting prephrased personalized text by individual physicians andnurses, and compiling the personalized text with the patient data forproducing medical English text summaries and reports.
 6. The method ofclaim 2, further comprising storing the text summaries in the peripheralCPUs, generating nurses' orders by entering physician orders to nurseswith touch screens, mouses and keyboards at the peripheral CPUs,transmitting the physician orders as physician orders data to the fileservers, storing physician orders data with the patient data in the fileservers, providing the physician orders data with the patient data fromthe file servers to the peripheral CPUs, compiling the physicians'orders data, patient data and the stored text summaries, and displayingthe physician orders data as textual nurses' orders on the displays,displaying all outstanding nurses' orders on the displays on request,displaying all nurses' orders specific to a patient on the display,entering executions of the nurses' orders on the display andautomatically changing the executed nurses' orders to nurses' textualnotes for display and printing in summaries.